DMAP Form .us



|[pic] |Substance Use Disorder Residential Treatment Admission/Discharge Notification Form |

|DIVISION OF MEDICAL ASSISTANCE PROGRAMS |Substance Use Disorder Residential Programs: Use this form to report when Oregon Health Plan clients enter or |

| |exit your program. |

| |Send the completed form via secure e-mail to DMAP Client Enrollment Services (CES) at ces.dmap@state.or.us. |

|CONFIDENTIALITY NOTICE: This document contains information which is confidential and/or legally privileged. The information is intended only for the use of the |

|individual or entity named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or taking of any |

|action in reliance on the contents of this information is strictly prohibited. If you have received this document in error, please immediately notify us via |

|secure e-mail at ces.dmap@state.or.us and destroy the documents received. Thank you. |

Client information

|1 Client Name |      |2 Client ID |      |

|3 Home Address |      |

|4 City State ZIP |      |5 Home County |      |

|6 Does this client have accompanying dependent child(ren)? | Yes | No |

|If yes, enter the dependent child(ren)’s name(s): |      |

Notification information

|1 Type of Notification (check one): |Adult admission |Adolescent admission |Discharge |

|2 Contact Person Name and Phone Number |      |

|3 Name and Phone Number of person who completed this form (if different from Contact Person): |

|      |

Program information

|1 Licensed Program Name: |      |

|2 Treatment Program Name and Address: |      |

|3 Treatment Program City State ZIP: |      |

|4 Provider Billing ID |      |5 Program capacity exceeds 16 beds? |Yes |No |

Admissions information – Report all admissions within 3 days of admission.

Do not bill DMAP or the CCO/MCO for newly admitted clients until DMAP CES confirms that they have processed your admission notification form. CES will notify you via secure email when this happens.

|1 Date of Admission |      |2 First Date of Service |      |

|3 Projected duration of stay (e.g., 90 days) |      |

|4 Current physical health enrollment (check one): |CCO |MCO |FFS |

| If enrolled in a CCO/MCO, enter CCO/MCO name: |      |

|5 Did you notify the CCO/MCO about this admission? |Yes |No |If no, please explain: |

| |      |

|6 If program is outside the CCO/MCO’s service area, did you ask the CCO/MCO for an out-of-area referral? |

| |Yes | No |If no, please explain: |      |

|7 How was the client referred to you? |Primary care |Court |Self | Outpatient program |

Discharge information

|1 Date of discharge |      |2 Referred to outpatient program? |Yes |No |

|3 If yes, outpatient program name: |      |

Substance Use Disorder Residential Program

Admission/Discharge Notification Instruction Sheet

Client information

|1 Client Name |Name of the person receiving treatment at your facility. Enter as listed on the client’s Oregon |

| |DHS Medical ID, Oregon Health ID or Plan ID. |

|2 Client ID |Enter the 8-digit identifier as listed on the client’s Oregon DHS Medical ID, Oregon Health ID or|

| |Plan ID. |

|3 Home Address |The client’s street address (where they lived prior to entering the treatment program).If the |

| |client is homeless, enter “Homeless.” |

|4 City State ZIP |The city, state and ZIP code of the client’s home address. |

|5 Home County |The county of the home address (not of the treatment program). |

|6 Does this client have accompanying dependents? |Check “Yes” or “No.” If the client has dependents residing with him/her at the treatment |

| |facility, also provide the dependents’ names. |

Notification information

|1 Type of Notification |Check “Adult admission,” “Adolescent admission” or “Discharge.” |

|2 Contact Person Name and Phone Number |This is the person we will contact if we have questions about information on this form. |

|3 Name and Phone Number of person who completed this form |If there is missing or invalid information on this form, we will contact this person first to ask|

| |them to resubmit the form. |

Program information

|1 Licensed Program Name |This is the name that appears on the actual license issued by AMH. |

|2 Treatment Program Name and Address |Enter the actual name of the program, if different from the licensed name. Also enter the |

| |physical address of the treatment facility. |

|3 Treatment Program City State ZIP |The city, state and ZIP code of the program’s physical address. |

|4 Provider Billing ID |Enter your 10-digit National Provider Identifier; or the 6- or 9-digit provider number issued by |

| |DMAP. |

|5 Program capacity exceeds 16 beds? |Programs that exceed 16 AMH-licensed beds are designated “Institutes for Mental Disease” (IMD). |

| |If you mark “Yes,” we will ensure that state (not federal) funds reimburse you for services. |

Admissions information

|1 Date of Admission |Enter the date the client was admitted to the facility for this report period. |

|2 First Date of Service |Enter the first billable date of service. |

|3 Projected duration of stay |Tell us how long the treatment plan will be (e.g., 90 days). |

|4 Current physical health enrollment |Tell us if the client is enrolled with a CCO or MCO, then enter the CCO/MCO name. If the client |

| |is enrolled with neither, select “FFS.” |

|5 Did you notify the CCO/MCO? |To coordinate care with the client’s CCO/MCO, you need to let the CCO/MCO know the client is at |

| |your facility. If you have not done this, please explain why. |

|6 Did you ask for an out-of-area referral? |If your program is outside the CCO/MCO’s service area, you need to coordinate with the CCO/MCO to|

| |make sure they will cover this service. If you did not ask for an out-of-area referral, please |

| |explain why. |

|7 How was the client referred to you? |Self-explanatory |

Discharge information

|1 Date of discharge |Enter the last day the client received treatment in your program. |

|2 Referred to outpatient program? |Enter Yes or No. |

|3 Outpatient program name |You must enter this information for all discharges. |

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